Advanced Age Is No Deterrent to Quality-of-Life Benefits of Epilepsy Surgery

Older adults who undergo surgery for drug-resistant epilepsy reap long-term quality-of-life benefits comparable to those of their younger counterparts. So found a study of more than 400 adults who underwent epilepsy surgery at Cleveland Clinic over a period of nearly a decade.

The study, which includes the largest quality-of-life dataset in patients with drug-resistant epilepsy undergoing surgery at age 60 or older, was published in Epilepsy & Behavior (2020 Dec;113:107574).

“Our findings indicate that epilepsy surgery should be considered for appropriate patients regardless of their age,” says Cleveland Clinic epileptologist Vineet Punia, MD, MS, lead author of the study. “Older adults and the elderly are just as likely as younger adults to report feeling better physically and mentally a year or more after surgery.”

Reluctance to operate on older patients

Although epilepsy surgery is the standard of care for drug-resistant focal epilepsy, older and elderly adults are often passed over for consideration. Many doctors assume that seizure control will have less of an impact on patients who may be better adjusted to their lifestyle or may no longer need to work or drive. But literature is scarce on how aging actually affects quality of life in patients with drug-resistant epilepsy, and the impact of epilepsy surgery on quality of life in different age groups had not been well explored prior to this study.

Study design and findings

Adults who underwent epilepsy surgery at Cleveland Clinic from January 2008 through October 2017 were included. All had taken the Quality of Life in Epilepsy 10 (QOLIE-10) survey before surgery and at a follow-up appointment at least one year after surgery. This validated survey includes general and epilepsy-specific domains including memory, mood, energy, driving, social and work limitations, and overall quality of life.

To make its cohorts comparable to earlier literature studies and to facilitate conversations with patients, the study separately analyzed patients older and younger than age 50, as well as older and younger than age 60.

Overall, 416 patients were analyzed, with the following profile:

• Average (± SD) age, 39.6 ±6 years
• 51% female
• 5% white
• Average (± SD) time from surgery to most recent follow-up QOLIE-10 survey, 1,155 ± 858 days (interquartile range, 391 to 1,770 days)

Of the 416 patients, 100 (24%) were 50 years or older, and 30 (7%) were 60 years or older. Pre- and post-surgery seizure frequencies were similar among the cohorts.

Key findings of the analysis included the following:

• Baseline QOLIE-10 scores and most recent QOLIE-10 follow-up scores were comparable between younger and older cohorts, whether dichotomized as < 50 versus > 50 or as < 60 versus >
• Significant within-group improvements from baseline to follow-up occurred in total QOLIE-10 scores and in most individual item scores. Improvements were comparable between younger and older cohorts, whether dichotomized as < 50 versus > 50 or as < 60 versus >
• The only significant difference between groups was on the question, “Have you felt down-hearted and blue?” In the < 60 versus > 60 analysis, the older group significantly improved from baseline, while the younger group did not.

In addition, two separate linear models were run to adjust for age at epilepsy onset and duration of epilepsy. Regardless of how the data were analyzed, age at surgery was not related to QOLIE-10 outcomes.

Conclusion: Age is not a factor

Dr. Punia emphasizes two major takeaways from the study:

• Quality of life of patients with drug-resistant epilepsy is similar regardless of age. Often, Dr. Punia points out, physicians harbor biased assumptions that older patients with epilepsy have fewer social roles and reduced needs around driving and employment, making surgery less important or beneficial for them. This was not borne out in the study.
• Epilepsy surgery’s impact on quality of life is independent of age. For almost every QOLIE-10 item, patients similarly improved after surgery, and the only significant difference found favored the oldest group.

“Epilepsy surgery is a highly effective therapy that is often needlessly underutilized in older patients,” concludes Dr. Punia. “This study can reassure neurologists that quality of life in well-selected older adults and the elderly stands to benefit as much as it does in their younger counterparts.”